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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OF"ICE USE: ' 1601 E. Hazelton Ave. , ;Stockton, Calif. <br /> Telephone f {209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued <br /> Triplicate) <br /> ) I <br /> 4 (Complete lete In p I <br /> o.� the San Joaquin Local Health District for a permit to construct <br /> Application is hereby made t <br /> and/or install the work herein described. This application is made in compliance with San Joaquin , <br /> and Regulations of the San Joaquin Local Health Dist#ct. <br /> County Ordinance No. 1$62 and the Rules <br /> r JOB ADDRESS/LOCATION / CENSUS TRACT <br /> ! • Phone <br /> Owner's Name - <br /> Address City .� <br /> Contractor's Name - zz..,,,.,/G �! ��c .License 4�. II SJ Phonee <br /> TYPE OF WORK (Check) : NEW WELL IX DEEPEN/ / RECONDITION -L <br /> PE <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLAC �� <br /> Other <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER-,LINES PIT PRIVY <br /> ' SEWAGEDISPOSAL FIELD `' CESSPOOL/SEEPAGE PIT OTHER \ <br /> PROPERTY LINE . PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE .TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> :Industrial } .. Cable Tool Dia. of Well Excavation ,2." ' <br /> Domestic/private- Drilled Dia. of Well Casing <br /> -—Domestic/ - "- Driven Gaugeof'CaSXng" <br /> Irrigation •GrAvel :P-ack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> { Disposal Other Other ..Information �I k <br /> r Geophysical `' '- - _- Surface .Seal Installed B <br /> Q t 4 <br /> PUMP INSTALLATION: Contractor �' <br /> r Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done - w <br /> PUMP .REPAIR: /7/ State Work 'Dbne oA t <br /> DES-TRUCTION OF WELL: Well Diameter <br /> 4. �r/;< - Approximate Depth , <br /> Describe Material and Procedure <br /> Irhereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN HAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District 6 <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in-use. The above <br /> information is true to". the jbest of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ; PRIOR TO UTING ANDA I S CT ION. <br /> TITLE nL <br /> SIGNED` <br /> (DRAW.PLOT PLAN ON REVERSE SIDE) <br /> j FOR-�DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> DATE ����� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: t ~' ` p II NAI. INSPECTION <br /> f PHA E II ROWINSPECTIO <br /> INSPECTION BY DATE 1'""__,._1NSPECTION BYv DATE .2 7 <br /> , 1177 2M <br /> n <br /> IT 7 J.OL n.___ 7-7L <br />